How to know if the child is tired from screaming or losing consciousness

[Sr Dingdong]

This is something that I have wondered a lot about after calls involving injured or sick kids in the past, and I recently went on a call to a 2 year old who had been scolded on a good part of her body which made me think about it again.
Initially the child was screaming a lot, which is to be expected. We were two ambulances on the scene, so I ended up driving the other ambulance. After maybe 10 minutes they mentioned on the radio that the child had stopped screaming, and I was wondering if that was bc the child was just exhausted from the screaming or if she was about to go into hypovolemic shock from the burns.
I was thinking that it probably was the former, but I dont know exactly how much of her body got burnt, or even how much has to be burnt before it starts to become a serious threat of losing so much fluids that she'll go into shock.
But anyways, how can you tell the difference between kids who stops screaming because they are getting tired from screaming for 15/20 minutes straight or if it is because of the injury affecting their consciousness?
Will a change in vital signs be the only way to know?

 

[RocketMedic]

Sounds like your medic couldn't effectively manage pain....which sucks. Ketamine FTW! (Nothing against them, many systems labor under archaic crappy protocols...and sometimes we can't help)

 

[Handsome Robb]

Sounds like your medic couldn't effectively manage pain....which sucks. Ketamine FTW! (Nothing against them, many systems labor under archaic crappy protocols...and sometimes we can't help)

To answer the OPs question vitals, skin signs and capillary refill are all good indicators. You can definitely use BP on a two year old however I wouldn't use it and it alone as NIBPs aren't accurate on kids generally and they're tough enough to auscultate sitting still without a screaming baby and diesel engine idling let alone adding road noise to the mix. Good luck palling one since we palpate brachial pulses in younger kids.

Definitely could be a protocol issue. I sure hope it was at least. Other potential reason and I hope it wasn't the reason was fear of using narcotics in pediatric patients, inability to start an IV and not thinking of (or not having) the option for intranasal fentanyl which in my experience works fantastically with pediatrics.

Fentanyl in any route works great for kids and they can handle a fair amount of it. One large dose (1-2 mcg/kg, I usually lean towards the 2 mcg/kg range if it will be under my max single dose of 100 mcg for both adults and pediatrics) followed by serial small doses works great. The midazolam and fentanyl cocktail great even though midaz has no analgesic properties from the aspect that if done correctly will put them down enough that they aren't or are barely awake to feel the pain. It can also be argued that midazolam has amnestic effects however that's been brought into question on more than one occasion. Grantedwhen using the cocktail there's still the physiologic response to the pain that may not be completely managed but without the proper pharmacological options we have to make what we have work.

Another option in this situation would be giving fentanyl and morphine back to back of you have that option. Unfortunately I have to pick one or the other and call to use both. You get the immediate effects of the fentanyl and as the fentanyl where's off the morphine will be kicking in keeping a more linear blood serum level which is more effective as well as better for the patient at managing pain. Do something like 2 mcg/kg of fentanyl followed by 0.1mg/kg of morphine. Another benefit from the morphine is the sedative effects it has.

Ketamine is awesome, I hate that we don't have it but our clinical department is pushing our MD hard for it. The argument against it is the remote possibility, albeit possibility, for laryngospasm. Had a patient it would've been perfect for the other day as the only way to effectively control her pain of her horrific proximal femur fracture that she's been laying on the floor with, screaming for help was enough fentanyl and midazolam to push her to the point of requiring 10lpm O2 via NRB to keep her SpO2 at 92-93% and she was still whimpering.

 

[ERDoc]

The most useful way to tell the difference is experience. It becomes one of those things that you know it when you see it. Definitely be concerned when a crying kid stops.

 

[Carlos Danger]

Fentanyl in any route works great for kids and they can handle a fair amount of it. One large dose (1-2 mcg/kg, I usually lean towards the 2 mcg/kg range if it will be under my max single dose of 100 mcg for both adults and pediatrics) followed by serial small doses works great. The midazolam and fentanyl cocktail great even though midaz has no analgesic properties from the aspect that if done correctly will put them down enough that they aren't or are barely awake to feel the pain. It can also be argued that midazolam has amnestic effects however that's been brought into question on more than one occasion. Grantedwhen using the cocktail there's still the physiologic response to the pain that may not be completely managed but without the proper pharmacological options we have to make what we have work.

Has the amnestic effect of midazolam been called into question? First I've heard of that.

 

[medicaltransient]

I like the above for IN fentanyl.

 

[Sr Dingdong]

Regarding the pain I think the problem was that they couldn't establish an IV. Not sure what they did, that was my first day in training as I am new to that ambulance service. They do have ketamine, but they can only give it IV, I think. They don't have a nasal spray. An anaesthesiologist met the ambulance en route to where the helicopter was picking the kid up, but he wasn't able to establish an IV either. Not sure if he did or could set an IO needle or what else was at his disposal.

So if I understand you correctly, you would always medicate a small child until they no longer scream? What if the allowed dosages according to your protocol isn't sufficient, as they in my experience often are not?

 

[Sr Dingdong]

The most useful way to tell the difference is experience. It becomes one of those things that you know it when you see it. Definitely be concerned when a crying kid stops.

Yes, I agree. In general a kid who stops screaming is a bad sign. But they have to get exhausted from screaming eventually, and I would like to know if it is a way to tell the difference between a child who is exhausted from screaming non stop for the last hour and a child that is going into shock or starting to lose consciousness from another reason.
Besides

 

[Carlos Danger]

So if I understand you correctly, you would always medicate a small child until they no longer scream?

No, you medicate (we are talking about analgesia, right?) until they are as comfortable as can be reasonably expected to be achieved. Not screaming would be part of that equation, sure, but a quiet kid isn't necessarily the goal.

What if the allowed dosages according to your protocol isn't sufficient, as they in my experience often are not?

You are right, that is often the case. What happens then is that the patient suffers.

 

[ERDoc]

So if I understand you correctly, you would always medicate a small child until they no longer scream? What if the allowed dosages according to your protocol isn't sufficient, as they in my experience often are not?

If it's available in your area, contact medical control or the hospital to get orders for more.

Yes, I agree. In general a kid who stops screaming is a bad sign. But they have to get exhausted from screaming eventually, and I would like to know if it is a way to tell the difference between a child who is exhausted from screaming non stop for the last hour and a child that is going into shock or starting to lose consciousness from another reason.
Besides

An exhausted child is usually arousable with somewhat normal vitals (depends on the situation though). A decompensating child will be much less arousable and bad VS. There is no hard and fast rule to make the determination, just the full clinical picture. The problem with kids is that their bodies are great at compensating, but once they tip, they crash fast.

 

[Handsome Robb]

Has the amnestic effect of midazolam been called into question? First I've heard of that.

I'll see if I can find what I was reading again. Basically said it does have amnestic effects but not as profound as many EMS education programs would have you believe. I was basically taught that versed = no memory of anything just prior to and for the majority of the effectiveness of the dose.

So if I understand you correctly, you would always medicate a small child until they no longer scream? What if the allowed dosages according to your protocol isn't sufficient, as they in my experience often are not?

That's not what I said at all. Just because your agency's protocols are narrow and don't allow proper analgesic doses doesn't mean that other areas don't have good analgesia protocols. Also, do you have a radio or cell phone? Call a damn doctor and circumvent your protocols and do what your patient needs.

 

[NomadicMedic]

Sadly, Neither of those above options would work for me. No fentanyl, so no IN pain management and there is no protocol for a benzo and opiate concurrently.

Also, I would probably not be able to obtain orders for additional medication or would I be able to convince a mid control doc to allow a benzo and opiate concurrently. I would make sure that I called for an airship and had the flight medics, who have significantly loser protocols, manage that patient

...and I agree, most paramedic education programs significantly oversell the amnesiac properties of Midaz. although, I have had patients tell me later that they don't remember anything about the event after getting a dose of versed.

 

[triemal04]

...and I agree, most paramedic education programs significantly oversell the amnesiac properties of Midaz. although, I have had patients tell me later that they don't remember anything about the event after getting a dose of versed.

I agree as well. But that's different than the actual amnestic effect being in question; just another symptom of the general state of education (or lack thereof).

 

[COmedic17]

I feel like you would have to have a kid to completely understand this.

Example- my daughter dropped ketchup on her foot, thought it was blood, and began screaming hysterically saying how bad her foot hurt. Another example- my daughter broke her collar bone after falling off sideways on a bike. She screamed bloody murder when it happened, but eventually calmed down when I stabilized her arm, and was even laughing and talking. After the X-ray when she heard the doctor say it was broken- she started screaming bloody murder again saying how bad it hurt- despite the fact it was fine 5 seconds before. Of course a broken collar bone hurts- but the pshychological component of her "pain" kicked in when she found out it was broken.

Pain is part visual and psychological, especially in children. Of course the burns hurt- but the excessive screaming is a mixture of the actual pain, and them just knowing they are hurt.


Monitor vitals (especially cap refill in young children), Give something for pain control, and for the love of God - cover it up as much as your able to (without irritating the injury) so the child can't see it.

If a child slowly stops crying but is still acting age appropriate, tracking you with their eyes, etc- I wouldn't be that concerned.


If they suddenly stop crying, and their LOC changes, then worry.

 

[Carlos Danger]

I'm not all that familiar with what they are teaching in paramedic programs these days about benzos, but in my experience and from what I have read, midazolam is a really potent amnesic. I would be interested in reading that piece that you mentioned, Robb.

As an example: about once a week I spend part of the day doing anesthesia for cataract surgeries. Normally, this consists of nothing but 2mg of versed in pre-op, and then a little more (most commonly 2 more, for a total dose of 4mg - but sometimes less, sometimes more) in the OR right before the surgeon gets started. Many of these people have already had this done on one of their eyes a couple weeks before and are coming back to get the second one done. When I'm going over what's going to go on with these folks in pre-op, they almost universally have no recollection at all - or only a very foggy recollection - of the first procedure. Granted, these tend to be older people, but many times I've heard the same thing from young, fit athletes who come in to get their shoulder or knee scoped for the second or 4th time. Even in people who regularly take benzos, while that generally blunts the sedative effect of a given dose, it seems to have less impact on it's amnestic effects.

Anyway, all that said, with the kid in the OP's scenario, IM opioid is where it's at. A big ole slug of morphine or demerol deep in the glute. Once that starts to take effect, then you can work on an IV or IO easier.

 

[COmedic17]

I'm not all that familiar with what they are teaching in paramedic programs these days about benzos, but in my experience and from what I have read, midazolam is a really potent amnesic. I would be interested in reading that piece that you mentioned, Robb.

As an example: about once a week I spend part of the day doing anesthesia for cataract surgeries. Normally, this consists of nothing but 2mg of versed in pre-op, and then a little more (most commonly 2 more, for a total dose of 4mg - but sometimes less, sometimes more) in the OR right before the surgeon gets started. Many of these people have already had this done on one of their eyes a couple weeks before and are coming back to get the second one done. When I'm going over what's going to go on with these folks in pre-op, they almost universally have no recollection at all - or only a very foggy recollection - of the first procedure. Granted, these tend to be older people, but many times I've heard the same thing from young, fit athletes who come in to get their shoulder or knee scoped for the second or 4th time. Even in people who regularly take benzos, while that generally blunts the sedative effect of a given dose, it seems to have less impact on it's amnestic effects.

Anyway, all that said, with the kid in the OP's scenario, IM opioid is where it's at. A big ole slug of morphine or demerol deep in the glute. Once that starts to take effect, then you can work on an IV or IO easier.

I concur.

I am perscribed Xanax as a sleep aid. Prior to Xanax, I was perscribed many other sleep aids such as ambien, trazadone, etc. I would sleepwalk on them. And sleep talk. And sleep drive. Etc. I take 2mgs of Xanax a night and don't move.


But when I went In for a routine surgery, it took "quadruple" (according to anistiology) the amount of benzo's to have any noticeable effect on me.